VANCOUVER, B.C. — Beneath a blue tarp that blocks out a gray sky, Jordanna Coleman inhales the smoke from a heated mixture of heroin and methamphetamine, sucking the addictive vapor deep into her lungs.

The drugs and pipe, acquired elsewhere, are hers. But the shelter, the equipment she uses to prepare her fix and the volunteers standing by to respond if she overdoses are provided by a small nonprofit. Funding and supplies come from the city of Vancouver and the province of British Columbia.

“I was outside. It’s warmer in here,” says Coleman, 22, although the tent is open to the damp and chill of a western Canadian winter. “It’s just safer.”

In barely a year, five sites like this one have opened within a few blocks of one another to contend with a surge of fentanyl on Vancouver’s streets. In December, the organization that runs this location, the Overdose Prevention Society, took over a vacant building next door, giving users a clean indoor place to inject drugs. There are 29 similar sites in British Columbia, the epicenter of Canada’s drug crisis, and more across the country.

“To save lives, you need a table, chairs and some volunteers,” said Sarah Blyth, the manager here. “We literally popped it up in one day. And then you have people saving lives. Immediately.”

As fentanyl rampages across North America, several U.S. cities have announced that they will open the first supervised drug-consumption sites like those in Canada. Their plans illustrate the gulf between the two nations: While Justin Trudeau’s government is doubling down on its “harm reduction” approach, any U.S. organization that tries to follow suit would be violating federal law and risking a confrontation with the Justice Department.

U.S. researchers say that at least one underground site is operating on American soil, and they predict that a public operation will open despite the potential consequences.

“That’s the way that drug policy issues have moved forward in this country [over the] last 25 years,” said Alex Kral, an epidemiologist at the think tank RTI International who has studied supervised drug consumption. Cities enduring the deaths, disease, crime and cost of drug epidemics have taken the lead in handing out free needles and distributing the overdose antidote naloxone — sometimes after legal battles.

February 11, 2018

OxyContin maker Purdue Pharma LP said on Saturday that it has cut its sales force in half and will stop promoting opioids to physicians, following widespread criticism of the ways that drugmakers market addictive painkillers.

The drugmaker said it will inform doctors on Monday that its sales representatives will no longer visit physician offices to discuss its opioid products. It will now have about 200 sales representatives, Purdue said.

“We have restructured and significantly reduced our commercial operation and will no longer be promoting opioids to prescribers,” the Stamford, Connecticut-based company said in a statement.

Doctors with opioid-related questions will be directed to its medical affairs department. Its sales representatives will now focus on Symproic, a drug for treating opioid-induced constipation, and other potential non-opioid products, Purdue said.

Opioids were involved in more than 42,000 overdose deaths in 2016, according to the U.S. Centers for Disease Control and Prevention.

Among other opioid producers, Endo International Plc (ENDP.O) agreed in July to pull its Opana ER painkiller after the Food and Drug Administration called for its withdrawal.

Purdue and other drugmakers have been fighting lawsuits by states, counties and cities that have accused them of pushing addictive painkillers through deceptive marketing.

The lawsuits have generally accused Purdue of downplaying OxyContin’s addiction risk and of misleading marketing that overstated the benefits of opioids for treating chronic, rather than short-term, pain.

At least 14 states have sued privately held Purdue. Alabama Attorney General Steve Marshall filed a lawsuit on Tuesday accusing Purdue of deceptively marketing prescription opioids.

Purdue is also facing a federal investigation by the U.S. Attorney’s Office in Connecticut.

February 08, 2018

Toronto District School Board high schools will soon be provided with a drug that can reverse opioid overdoses.

On Wednesday evening the board voted to move forward with equipping every secondary school with a naloxone kit, as part of TDSB’s overdose-prevention plan implemented in November 2017.

TDSB spokesperson Ryan Bird said one kit will be provided to each of the board’s 112 high schools and alternative schools.

Two to three staff from each school will also be trained on how to use the kit.

Bird said the training will led by the TDSB and it will begin just before March break and should be finished before the end of April.

TDSB’s initiative is in response to the City of Toronto’s action plan on the rise of overdoses.

In 2016 there were 2,861 opioid-related deaths in Canada. From January to June 2017, there were at least 1,460 suspected opioid-related deaths. “It is expected that this count will rise,” the Public Health Agency of Canada stated.

The city’s report, released in March 2017, encouraged school boards to consider having naloxone kits.

Toronto Public Health assisted TDSB on how the board could obtain naloxone kits and go about training, said Dr. Rita Shahin, TPH spokesperson and associate medical officer of heath.

Bird said TDSB members who have already been trained by TPH on how to use the kits will then teach staff at the other 112 schools. “We’re using a trainee-becomes-a-trainer model.”

Training will include instruction on how to identify signs and symptoms of an opioid overdose, and how to administer the nasal spray, and then call emergency services.

He said the board will be covering the costs for the kits, which will amount to between $16,000 and $20,000.

Bird said he is “not aware” of any suspected overdoses in TDSB schools. “This is not something we would track centrally. I’m not personally aware of anything like that.”

TPH also said they are not aware of any suspected overdoses in schools.

Bird said the board is looking into how they educate their students about the opioid crisis, the dangers of fentanyl and how to ensure their safety when it comes to drug use, but the TDSB has not come up with any specific methods yet.

February 01, 2018

A majority of the public considers addiction to prescription pain medication a major problem nationally (53%) but does not deem it a national emergency (28%) (Politico–HSPH, 2017). Substantially fewer people see it as an emergency (16%) or a major problem (38%) in their own community (PBS–Marist, 2017). In a list of national health problems, abuse of prescription painkillers ranks fifth in the proportion of the public that considers it an extremely serious disease or health condition facing the country (28%; KFF, April 2016).

Concern about prescription-drug abuse as a public health problem has grown over time. Nearly 4 in 10 people (38%) currently believe it’s an extremely serious public health problem, double the proportion (19%) who believed so in 2013 (Pew, 2013 and 2017). More than 6 in 10 (63%) believe that the problem of addiction to prescription pain medications has increased in the past year, 26% think it has stayed about the same, and only 2% believe it has decreased (PBS–Marist, 2017).

The public is divided over which level of government bears the most responsibility generally for fighting addiction to prescription pain medicine: 36% said the federal government was most responsible, followed by state (28%) and local (21%) governments (PBS–Marist, 2017).

Similarly, asked what level of government should be primarily responsible for paying for programs aimed at reducing the number of people abusing prescription painkillers or opioids, about 41% said the federal government, versus 33% for state and 20% for local.

Democrats are significantly more likely than Republicans (52% vs. 29%) to believe the federal government should be mainly responsible (Politico–HSPH, 2017). Asked about general responsibility beyond government, nearly half (47%) said the medical and mental health community bears the most responsibility for fighting opioid addiction, while 29% named the pharmaceutical industry and 12% the law-enforcement community (PBS–Marist, 2017).

As to Trump’s proposed national response, most of the public does not share the view of some media commentators that the proposed program does too little. Only 27% believe it does too little, 10% believe it does too much, and 41% believe it’s about right. Asked about the spending for treatment in the proposal, 19% said it’s too low, 18% too high, and 44% about right. A large proportion — about one in five — said they did not know enough to give an opinion on either of these questions (Politico–HSPH, 2017).

Asked who is mainly responsible for the growing problem, the public placed the most blame on doctors who inappropriately prescribe painkillers (33%) and people who sell prescription painkillers illegally (28%). Only 10% believe that people who take prescription painkillers are mainly responsible (Politico–HSPH, 2017). A majority believe that people addicted to painkillers have an illness (53%) rather than a personal weakness (36%) (PBS–Marist, 2017).

The B.C. Coroners Service says more than 1,400 people died of an illicit drug overdose in the province in 2017, making it "the most tragic year ever," according to the chief coroner.

Lisa Lapointe said the preliminary total for the year is at 1,422 — an increase of 43 per cent from 2016 — but that figure will grow as test results continue to come in.

Approximately 81 per cent of suspected deaths last year involved the opioid fentanyl. Lapointe said it was often combined with other illicit drugs — most often heroin, cocaine or methamphetamines.

"If not for fentanyl, we wouldn't be seeing the deaths we're seeing," she said Wednesday.

Nearly 90 per cent of people who died were alone inside a home when they suffered an overdose. Four out of five were men, and more than half of all victims were between the ages of 30 and 49.

Vancouver saw the highest number of deadly overdoses last year, followed by Surrey and Victoria.

The coroners service said nobody died at any supervised consumption site or at any of the drug overdose prevention sites.

The number of deaths in 2017 had surpassed the 2016 record of 923 by October.

The provincial health crisis, first declared in 2016, has continued into the new year: nine deaths were reported over five days in the B.C. Interior last week.

Provincial health officer Dr. Perry Kendall, speaking on his last day before retirement, said the numbers show the province is still in the middle of an "epidemic of poisoning deaths."​

Indigenous people in B.C. were also disproportionately affected by the crisis in 2017 — Dr. Patricia Daly said they accounted for 10 per cent of all illicit overdose deaths in B.C. last year, even though they only represent 3.4 per cent of the provincial population.

'Cautiously optimistic'

However, Daly said there is a glimmer of hope in the numbers.

She said statistics show a "significant decrease" in deaths over the last four months of 2017: an average of 96 deaths per month from September to December, compared with the first eight months of the year when there were more than 129 deaths per month.

Daly said she's "cautiously optimistic" about the 25 per cent drop.

"Things are moving in a better direction ... but I'd say it's too early to say it's an ongoing downward trend," she said.

January 25, 2018

Hundreds of millions of dollars worth of fentanyl — and likely more — is pouring into the United States through international mail — and the federal government isn’t equipped to track it or prevent it from happening, according to a nearly yearlong bipartisan Senate investigation.

The 100-page report, released Wednesday from Sens. Rob Portman (R-Ohio) and Tom Carper (D-Del.) and conducted by the Senate’s permanent subcommittee on investigations, looked at just six online sellers offering fentanyl — the powerful opioid implicated in a growing number of overdose deaths. Five are based in China; investigators could not confirm the location of the sixth.

Those vendors — all found through a simple Google search — sent hundreds of packages to more than 300 U.S. based individuals And they primarily used the government’s own U.S. Postal Service to carry the illicit cargo.

“Thanks to this bipartisan investigation, we now know the depths to which drug traffickers exploit our mail system to ship fentanyl and other synthetic drugs into the United States,” Portman said in a statement. “The federal government can, and must, act to shore up our defenses.”

Connecting sellers to buyers

By subpoenaing Western Union for payment information related to the six online sellers, investigators identified $230,000 in payments in 500 financial transactions with U.S.-based individuals or businesses — an amount that would translate into $766 million worth of fentanyl, based on its U.S. street value. The investigators linked that same data to USPS, FedEx, and other private shipping companies, which allowed them to identify recipients and find packages they received in a similar time frame.

Through that work, the investigators determined that seven individuals had died of a synthetic opioid overdose after a transaction with one of the online sellers. One Ohioan, for example, had paid an online seller $2,500 between May 2016 and February 2017 and received some 15 packages through the Postal Service during that time. He overdosed on a synthetic opioid less than a month after receiving one such package.

You might think that the kind of extreme poverty that would concern a global organization like the United Nations has long vanished in this country. Yet the special rapporteur on extreme poverty and human rights, Philip Alston, recently made and reported on an investigative tour of the United States.

Surely no one in the United States today is as poor as a poor person in Ethiopia or Nepal? As it happens, making such comparisons has recently become much easier. The World Bank decided in October to include high-income countries in its global estimates of people living in poverty. We can now make direct comparisons between the United States and poor countries.

Properly interpreted, the numbers suggest that the United Nations has a point — and the United States has an urgent problem. They also suggest that we might rethink how we assist the poor through our own giving.

According to the World Bank, 769 million people lived on less than $1.90 a day in 2013; they are the world’s very poorest. Of these, 3.2 million live in the United States, and 3.3 million in other high-income countries (most in Italy, Japan and Spain).

As striking as these numbers are, they miss a very important fact. There are necessities of life in rich, cold, urban and individualistic countries that are less needed in poor countries. The World Bank adjusts its poverty estimates for differences in prices across countries, but it ignores differences in needs.

An Indian villager spends little or nothing on housing, heat or child care, and a poor agricultural laborer in the tropics can get by with little clothing or transportation. Even in the United States, it is no accident that there are more homeless people sleeping on the streets in Los Angeles, with its warmer climate, than in New York.

The Oxford economist Robert Allen recently estimated needs-based absolute poverty lines for rich countries that are designed to match more accurately the $1.90 line for poor countries, and $4 a day is around the middle of his estimates. When we compare absolute poverty in the United States with absolute poverty in India, or other poor countries, we should be using $4 in the United States and $1.90 in India.

Once we do this, there are 5.3 million Americans who are absolutely poor by global standards. This is a small number compared with the one for India, for example, but it is more than in Sierra Leone (3.2 million) or Nepal (2.5 million), about the same as in Senegal (5.3 million) and only one-third less than in Angola (7.4 million). Pakistan (12.7 million) has twice as many poor people as the United States, and Ethiopia about four times as many.

Angus Deaton is the co-author of a major study of the disastrous impact of poverty on the American working class, which is causing American life expectancy to fall after many decades of rising. I wrote about it two years ago; it's at the core of the North American opioid epidemic and gun violence. And it's hurting women even more than men.

Eighty per cent of people who died from an illicit substance overdose in the Fraser Health area had received care in the emergency department at least once in the 12 months before their death, says a health authority report released on Monday.

Previous visits were not just for illicit drug overdose — most sought care for injury, trauma, back pain, alcohol overdose or mental health.

Close to 2,000 British Columbians have died of illicit drug overdoses since a public health emergency was declared two years ago. The Fraser Health region has one of the highest number of illicit drug overdose deaths in the province.

Dr. Victoria Lee, chief medical health officer for Fraser Health and author of the new report, said the research highlights a critical issue of self-medication.

"People that are using substances are self-medicating whether it's because of pain that's physical or emotional or underlying trauma," she said. "They feel isolated, they don't feel like they are part of our broader society or community."

One of the goals of the report is to have a better understanding of the factors leading to illicit substance abuse and to help identify those at risk of an overdose, Lee told CBC host of On The Coast Gloria Macarenko.

Profile of an overdose

The report examined approximately 45,000 visits to emergency rooms and 5,000 patients to learn more about the fatal and non-fatal overdoses in the region.

In the Fraser Health region, 85 per cent of the deaths were male, with 30- to 39-year-olds having the highest number of overdose deaths.

A disproportionate number of men who overdose were currently or formerly employed in trade industries, Lee added.

Despite the prevalence of overdose deaths in media headlines and within policy discussions, Lee said the issue remains a hidden epidemic in many ways.

"Unlike what most people think of, 70 per cent of people are actually dying in private residences or at their homes," Lee said. "A lot of what is happening is actually hidden from what we normally see or think of in terms of opioid epidemic."

She said that combating the stigma of substance abuse is critical to encouraging people to seek help.

Objectives. To compare US trends in rates of injection drug use (IDU), specifically opioid injection, with national trends in the incidence of acute HCV infection to assess whether these events correlated over time.

Methods. We calculated the annual incidence rate and demographic and risk characteristics of reported cases of acute HCV infection using surveillance data from 2004 to 2014 and the annual percentage of admissions to substance use disorder treatment facilities reporting IDU for the same time period by type of drug injected and demographic characteristics. We then tested for trends.

Results. The annual incidence rate of acute HCV infection increased more than 2-fold (from 0.3 to 0.7 cases/100 000) from 2004 to 2014, with significant increases among select demographic subgroups. Admissions for substance use disorder attributed to injection of heroin and prescription opioid analgesics increased significantly, with an almost 4-fold increase in prescription opioid analgesic injection. Significant increases in opioid injection mirrored those for reported cases of acute HCV infection among demographic subgroups.

Conclusions. These findings strongly suggest that the national increase in acute HCV infection is related to the country’s opioid epidemic and associated increases in IDU.

January 18, 2018

Unless Republicans coalesce this week around a short-term spending deal, the federal government will shut down — a scenario that will likely have widespread and long-lasting consequences for public health.

The Food and Drug Administration would likely have to forgo updating mislabeled medications or conducting routine food safety inspections. The Centers for Disease Control and Prevention would furlough key staff amid one of the most severe flu seasons in recent memory. And the National Institutes of Health might have to stop enrolling hundreds of patients in clinical trials.

All of the federal government’s health agencies, moreover, would be hamstrung in their efforts to help address and coordinate a response to the ongoing opioid epidemic.

That’s according to federal staffers who’ve lived through this before, and documents outlining each agency’s contingency plan for previous fiscal years.

The 2013 government shutdown “was a very challenging time,” said Dr. Margaret Hamburg, who at the time was the FDA commissioner. “[It was] extremely disruptive to the critical, unique, and essential work of the FDA. … Important programs dramatically slowed or halted without the needed staff. Even for those essential time-urgent activities, available staff — professional and support — were stretched dangerously thin.”

The shutdown “was this time in which that I felt I really couldn’t do my job, as CDC director, of keeping Americans safe, because more than 8,500 of my staffers had been told to go home, and they do important things that protect Americans,” said Dr. Tom Frieden, who was in charge of the CDC during the 2013 government shutdown. He is now CEO of Resolve to Save Lives, a philanthropic global health campaign overseen by the nonprofit Vital Strategies. “It’s unsafe, it’s terrible for government, it endangers Americans, and it doesn’t save any money. So it’s a really bad thing to have happen.”

Broadly, the Health and Human Services Department would likely furlough about 41,000 of its 82,000 workers, according to a fiscal year 2017 contingency plan. The plan hits different agencies differently — about 55 percent of FDA staff, for example, would keep working, while only about 10 percent of the Substance Abuse and Mental Health Services Administration workforce would stay on board, per that plan. At the CDC and NIH, 39 percent and 23 percent of each respective agency’s employees would remain in place.

In every previous shutdown, Congress has allocated back pay for all furloughed federal employees. Shutdowns, then, don’t save the federal government money. The 2013 shutdown cost the government $24 billion, according to the ratings agency Standard & Poor’s.

Agency staff have some limited discretion to interpret the statutes that govern which employees can continue to work. Staff whose jobs are funded by mandatory appropriations or by outside spending — like some of those involved in the FDA’s user-fee-funded programs — can generally keep working. So, too, can staff whose work relates to “activities that involve the safety of human life and protection of property,” per several earlier contingency plans.

When asked to comment on this year’s plan, the FDA, CDC, and NIH referred STAT to the Office of Management and Budget, which did not respond.